Patients as Health Producers: The Psychosomatic Foundation of Lifestyle Medicine
Authors: Giovanni A. Fava
Journal: Psychotherapy and Psychosomatics (2023)

Current healthcare is still conceptualized in terms of acute care perceived as a product processing, where the patient is a customer who can, at best, select among the services that are offered. Yet, in the early nineties, Julian Tudor Hart, a retired primary care physician, pointed out that in healthcare the product is clearly health and the patient is one of the producers, not just a customer [[1]. As a result, "optimally efficient health production depends on a general shift of patients from their traditional roles as passive or adversarial consumers, to become producers of health jointly with their health professionals, in an essentially co-operative rather than competitive public service" [[1] [p. 383]. It is worth examining this extraordinary paper, much ahead of its time, as to the role of patients and physicians as health producers and of psychosomatic medicine as the conceptual framework of health production.Hart identified two major aspects of patients' activities as producers [[1]. One was concerned with the fact that what we do in our daily lives profoundly affects our health and quality of life [[1]. Practicing regular physical activity, not being overweight, following sound nutrition, getting adequate sleep, and refraining from smoking and substance abuse have been found to have a key role on health in an impressive number of studies in the general population [[2]. In the same vein, unhealthy lifestyle is a recognized risk factor for most prevalent disorders, such as metabolic and cardiovascular diseases [[2]. Awareness of the importance of lifestyle medicine has progressively increased over the past decades, with its recommendations becoming a key component of most guidelines concerned with prevention and treatment of diseases [[3]. While targeting the persons at the highest risk of developing diseases may yield disease prevention, switching the general population to healthy lifestyles may entail health promotion and more general benefits for the society at large [[4].The other important aspect of health production is concerned with the participation of patients in their own management [[1]. The partnership paradigm includes both collaborative care, a patient-physician relationship in which physicians and patients make health decisions together, and self-management, a plan that provides patients with problem-solving skills to enhance their self-efficacy [[5]. Evidence from controlled trials indicates that programs teaching problem-solving skills and self-management may improve clinical outcomes and reduce costs [[5].Hart formulated a sharp criticism of the medical system as a source of health production, with special reference to the insufficient time for medical consultations [[1]. His remarks are more timely today than in the early nineties. There is extensive evidence that in general medical practice most final diagnoses can be derived from clinical history and physical examination [[6]: patients will usually tell us the diagnosis if we let them [[1]. There is also increasing awareness of the importance of shared decision-making, in which the clinician and patient go through all phases of the clinical process, share treatment preferences, and reach an agreement on treatment choices [[7]. In many cases, problem areas may be amenable to improvement through provision of medical information and adequate explanation. This is particularly important for individuals with limited health literacy, who would otherwise be prone to worse self-management, lower use of preventive services, and higher hospitalization rates [[8]. Unhurried shared decisions are necessary for providing strength and credibility to suggestions for lifestyle modifications [[1]. Yet, current healthcare trends privilege expensive tests and procedures and tag the time devoted to clinical history as lacking cost effectiveness [[6]. Not surprisingly, both in general and clinical populations, the success of promoting healthy lifestyle has been rather modest, as exemplified by the growing figures of epidemics such as obesity in children [[2].Hart remarked that patients are conceived as consumers by the process of industrialization of medical care and the influence of pharmaceutical companies, with consultation as a point of sale and consumption [[1]. He summarized the contrast between consumer and producer as follows: in general, patients as passive consumers have unrealistic expectations, their disappointments often leading to further inappropriate clinical decisions, particularly where these are a profitable marketed commodity. Every patient who, having brought a want to a doctor, receives not a prescription or a referral but explanation and understanding has moved, however, slightly from passive consumption toward active production of health" [[1] [p. 384]. The achievements of pharmaceutical propaganda have been spectacular: physicians who either buy that propaganda or use it for personal financial and power gains (special interest groups) have caused an unprecedented increase in the use of medications in the patient population [[9]. By exaggerating the importance or benefits of a product, commercial strategies lead to limitless expectations for new medications and technological devises [[10]. Such an approach helps generate public interest and funding for what are sold as "breakthrough discoveries" [[10]. Encouraged to consume, people want to believe that they can gain health without effort [[1] and are unlikely to accept strategies such as lifestyle modification that require considerable effort and persistence.In the late sixties, Lawrence Hinkle advocated the endorsement of an ecological approach in medicine during his presidential address at the annual meeting of the American Psychosomatic Society [[11]. The term "ecology" was certainly not common in those days: it meant relating biochemical, physiological, and psychological disorders to the social environment [[11]. In the same year of the presidential address, George Engel developed a multifactorial model of illness [[12], later subsumed under the rubric of "biopsychosocial" [[13]. It allows illness to be viewed as the result of interacting systems at the cellular, tissue, organismic, interpersonal, and environmental levels. These ecological relationships, such as the social inequalities that affect health and the unexplained variance in health outcomes, were neglected for decades and only recently appraised again [[14]. Bruce McEwen, a neuroscientist who supported the psychosomatic view of medicine, had a major role in expanding the concept of lifestyle, initially restricted to nutrition, fitness, sleep, and refraining from smoking and substance abuse [[15]. From his initial research on fundamental physiological mechanisms of stress in classic animal models, McEwen expanded his focus to psychological, social, and economic factors that shape lifestyle in life-course trajectories of human health [[15]. His notion of allostatic load (the cost of chronic exposure to fluctuating or heightened neural and systemic physiologic responses exceeding the coping resources of an individual) provides a synthesis of the cumulative effects of biopsychosocial experiences in daily life that involve chronic stress, life events, as well as work experience, unemployment, adverse living conditions, social and educational experiences, and income inequality throughout life span [[16]. This comprehensive model also encompassed the physiological consequences of the resulting health-damaging behaviors, including poor sleep and other aspects of circadian disruption, unhealthy diet, smoking, alcohol, and drug consumption [[16, 18]. When stressful circumstances exceed the individual's ability to cope, then allostatic overload ensues, with major negative health consequences [[19]. In recent years, there has been increasing awareness of the importance of a number of environmental issues in modulating health: the built environment (e.g., quality of housing, conditions of living, neighborhood walkability); the availability of green space; air pollution and environmental exposure to toxic elements, particularly at work; food access, availability, and affordability; access to healthcare [[20]. Lifestyle is not necessarily dependent on individual choices; it may also be a direct consequence of poverty, lack of education, and dramatic events such as wars. In 1948, James Halliday, a primary care physician, who was also an epidemiologist and a public health administrator, wrote a book on the links between stress, lifestyle, and social sickness [[21]. Indeed, large improvements in health might be achieved by enhancing public life and improving housing, work conditions, environment, contact with nature, practicing sports [[15]. Addressing unemployment, that deprives people of personal identity, social contacts, material assets, and meaning of life, may be another important area of intervention. Incorporating allostatic load in the clinical evaluation allows a view of illness within the interaction between the individual and the social environment, including factors that make individuals susceptible to disease, resilient when disease occurs, and variably responsive to treatment [[14].Bruce McEwen called attention to the modulating role of euthymia in determining vulnerability to allostatic load [[22]. Euthymia is a construct characterized by lack of mood disturbances; presence of positive affect (e.g., cheerfulness, ability to relax); balance of psychological well-being dimensions, flexibility, consistency, and resistance to stress [[23]. Unlike previous models related to psychological well-being which are exclusively focused on the intra-individual level, euthymia results from interacting mechanisms at the individual, interpersonal, and environmental levels. These latter include work, unemployment, adverse living conditions, social and educational experiences, income inequality, stressful life circumstances, racism, and sexism [[14, 23].The allostasis model defines health as optimal predictive fluctuation, since increased demand calls for increased response capacity [[16, 19]. McEwen pointed out that "…euthymia means using allostasis optimally and maintaining a healthy balance that promotes positive aspects of brain and body health through health-promoting behaviors. These behaviors involve not only diet but also adequate and good quality sleep, positive social interactions, as well as positive physical environment that is safe and includes green space, all of which reduce allostatic load." [[22] [p. 58].In clinical settings, an effective use of the principles of lifestyle medicine represents a substantial opportunity to improve health outcomes [[2]. Nearly all physicians are aware of these principles, and yet they are able to transmit them effectively only to a minority of people in the general population [[2]. The problem is that simple recommendations and suggestions are unlikely to sort out any substantial effect because the problem is more complex than what we generally envision. First, I will share some insights I gained during my clinical and research experience in psychiatry, a medical specialty which makes minimal use of lifestyle change opportunities. I will then refer to how these insights may be relevant to the general practice of lifestyle medicine.In the nineties I was particularly concerned about the high risk of relapse in depression and its link with residual symptomatology [[24]. It was not easy to make the patients better, but it was even more difficult to keep them well. I introduced a sequential strategy: first, treatment with antidepressant drugs and then cognitive behavioral treatment of residual symptoms [[25]. A first controlled trial was promising [[26], but I felt that what I had developed was not sufficient. I was looking for a strategy that could increase the level of recovery, and I thus developed a psychotherapeutic technique for modulating psychological well-being, Well-Being Therapy (WBT) [[27]. However, I thought that a change in lifestyle was also necessary, as it was found to be the case with type-A behavior in cardiovascular medicine [[28]. This is why I decided to include cognitive behavioral treatment, WBT, and lifestyle modification in the treatment package in a controlled study concerned with patients with a severe form of recurrent depression [[29]. Treatment started after depressed patients achieved remission with pharmacotherapy and consisted of 10 individual sessions of 30 min each every other week by the same physician who had administered antidepressants [[29]. The sequential approach yielded very impressive results in terms of relapse rate compared to a group where clinical management was used [[29] and was subsequently replicated by many other investigators [[25]. A number of insights were generated by that therapeutic trial, where I personally treated all patients [[29]. I believe that these considerations are relevant to any work that deals with the practice of lifestyle medicine, and yet they are seldom addressed [[2, 3].Which was my personal clinical background? The use of lifestyle medicine was (and still is) very limited in psychiatry (e.g., obesity as a complication of medications) [[30]. There were very few experiences to rely on. I was familiar with the use of homework exposure [[31] in patients with panic disorder associated with agoraphobia [[32]. Even though this type of therapy (assigning specific homework to be carried out by the patient alone in the intervals between psychotherapy sessions) was commonly known as "behavioral," it had some overlaps with lifestyle medicine, in the sense that its aim was to gradually move the person from a very restricted way of living (e.g., housebound) to getting exposed to outside environment and social situations. As a result, I thought that adding in the patient's diary some graded suggestions in terms of lifestyle was the way to go [[29].The overall management departed from standard lifestyle strategies [[2, 3]. A first characteristic was the individual focus. Lifestyle modification packages tend to be applied as a general, undifferentiated strategy. In our case, the modalities and timing of application varied from one individual to another and were preceded by an adequate assessment. A second characteristic of our approach was concerned with the degree of motivation that we were able to induce. An example I made in the study [[29] was as follows: "when I first saw you, you were very depressed. You went off the road. I gave you antidepressant drugs and these put you back on the road. Things are much better now. However, if you keep on driving the way you did, you will go off the road again, sooner or later." Such motivational issue was reinforced at each session. We should consider that positive results that are achieved only in the short term may be useless, if not detrimental, if they are not maintained in the long term, as the findings on the morbidity associated with regaining weight in obesity dietary treatment remind us [[33]. A further motivational element was brought by WBT [[27], that reinforces the importance of considering euthymia as a general target [[23]. There is now preliminary evidence from controlled studies that benefits may ensue by associating lifestyle modification with WBT [[34, 35]. A third key characteristic was the fact that lifestyle suggestions were incorporated into a general treatment strategy, with the use of macro-analysis [[36]. Macro-analysis includes any problems (not necessarily diagnoses) that are perceived by the clinician to be important. A relationship between co-occurring syndromes and problems is established in terms of clinical priority [[36].If psychiatry may become a source of insights for lifestyle modification, lifestyle medicine may offer unprecedented opportunities for psychiatric practice. The examples that were selected in Table 1 include restricted lifestyle associated with the avoidance patterns of phobic disorders such as agoraphobia and social phobia [[31]; consideration of stressful life circumstances in evaluating and addressing the problems of relapse in mood and anxiety disorders [[37]; role of allostatic load in modulating treatment response and adherence [[18, 19]; the general tendency of psychiatric patients to take worse care of their health, that may worsen medical comorbidity [[38]; the detrimental effects of ultra-processed food addiction on binge-type eating disorders, obesity, and diet-related disorders, which call for policies for their reduced accessibility in the modern food environment and their reformulation to reduce their addictive potential [[39]; the need of introducing lifestyle suggestions at the time of prescription of psychotropic drugs that may induce weight again [[40], with the same modalities that psychiatrists use for MAO inhibitors, instead of waiting for the occurrence of obesity which is then difficult to modify [[30]. Attention to lifestyle and self-therapy, however, requires a model of clinic that substantially departs from standard psychiatric outpatient services and may pave the ground for an innovative approach to mental health in the medical setting [[41].Addressing the origins of disparities in physical and mental healthcare early in life is likely to produce greater effects than attempting to modify health-related behaviors later or to improve access to healthcare in adulthood [[42]. Attention to lifestyle issues in psychiatry, such as reducing exposure to ultra-processed food [[39], appears to be particularly important in childhood and adolescence.Cardiology is a medical specialty that, unlike psychiatry, has dedicated considerable attention to lifestyle issues [[2]. In an important paper that has recently appeared in Circulation [[43], a Science Advisory Panel of the American Heart Association has provided discussion of the strategies for promotion of healthy lifestyle in clinical settings. The starting point was the fact that the vast majority of the US population does not meet recommendations for a healthy lifestyle, particularly as to dietary patterns, physical activity, avoiding exposure to tobacco products, and attaining adequate amounts of sleep. Greater promotion of health may ensue if physicians or other healthcare providers effectively motivate and initiate patient behavior change [[43]. A model based on 5A was purported: assess (understanding what is the current lifestyle behavior and why it should be changed or improved); advise (discussing the health risks and benefits of behavior change); agree (setting goals for behavior change); assist (encouraging solutions and action steps); and arrange (providing access to resources and follow-up on progress). The approach was designed to be brief (less than 15 min of physician time) and had to focus on a single lifestyle issue for each clinical encounter. In the course of time, in an incremental fashion, additional lifestyle issues could be addressed [[43].The position paper of the American Heart Association [[43] certainly represents a welcome and important step to health production that acknowledges the potential role of clinicians in initiating behavior change. However, some questions arise about its implementation in everyday practice. Are 15 min sufficient as time investment for lifestyle medicine? or do we need to reconsider all priorities in the clinical process? In the paper of the American Heart Association [[43], the emphasis was on nutrition, physical activity, smoking, and sleep, with very few considerations on psychological well-being and stress that were formulated in outdated clinical terms. In particular, there was no reference to allostatic load [[16, 19], which may provide a unitary clinical concept linking lifestyle with stressful life circumstances, social determinants of health, anxiety, depression, and euthymia. It is also astonishing how individual health attitudes and behaviors were neglected, despite the fact that they have such profound influences on lifestyle [[7]. The lack of psychosomatic framework for assessment is clearly a major flaw of the strategies that were suggested.Health behavior is concerned with any behavior that affects health status [[7]. Motivating people to make beneficial changes in their behavior is now regarded as a current major healthcare challenge [[2, 43]. There is also increasing appraisal of the importance of psychosocial determinants of health and of patients' self-management [[2, 7, 14]. There is very little recognition, however, that health promotion requires major clinical, financial, and organizational changes in the healthcare system. Keeping the patient in the passive role of medication consumer is fully in line with the prevailing corporate interests of current medicine [[44]. If people become health producers, they may criticize current organization of healthcare and allocation of resources, including research funded by taxpayer money. They may also raise basic environmental, social, and educational issues. Physicians who choose to promote health and not simply of treating disease have no choice but pursuing intellectual freedom and critical thinking in clinical practice and research. They are likely to challenge corporate interests that control media, scientific societies, and clinical practice guidelines. What could be more dangerous to the current establishment than switching the patient from the current role of consumer to health producer?Prof. Giovanni A. Fava has no conflicts of interest to declare.Prof. Giovanni A. Fava has no funding to declare.Prof. Giovanni A. Fava conceived and wrote the entire manuscript.